Care Home: New Hutte Lane, 9

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What the care home does well 9, Newhutte Lane was decorated and furnished to a good standard. The bedrooms of the people living in the home had been personalised and the home continued to receive ongoing investment as required. The people using the service appeared relaxed and comfortable in their home environment. Staff were observed to interact with service users in a positive manner and demonstrated a good understanding of each person`s needs, preferences and preferred routines. An advocate for the people using the service reported; "I`m quite happy with the service provided" and "The staff do what they can to ensure the men are properly looked after." Essential Lifestyle plans had been developed to ensure key information on each person living in the home had been identified and planned for. A range of supporting documentation was also available and this provided evidence that the health care needs of the people using the service were maintained and that service users were encouraged to participate in a range of social and recreational activities. Discussion with staff and examination of training records confirmed staff had access to ongoing training and supervision as part of their role. Records showed that new staff had been correctly recruited and that the welfare of vulnerable adults was protected. There had been one complaint since the last visit which had not been upheld (Please refer to the section entitled `Concerns, Complaints and Protection` for more information). Records showed that the complaint had been acknowledged and investigated by a senior manager within the Organisation (Brothers of Charity). What has improved since the last inspection? Since the last inspection, risk assessments had been updated to ensure potential / actual risks had been individually assessed in order to improve record keeping and accountability. Activity records had also improved and provided more detailed information on the range of activities undertaken by the people using the service. A menu plan had been developed and records of deserts were available to confirm service users received a varied, balanced and nutritious diet. Health Action Plans had been updated and included information on the outcomes of medical appointments. The date, quantity and initials of the person receiving medication into the home had been recorded on Medication Administration Records to provide an audit trail. A copy of the Local Authority`s Adult Protection Procedures had been obtained for staff to reference and staff spoken with demonstrated a good understanding of how to recognise and / or respond to suspicion or evidence of abuse. The Registered Manager had commenced a National Vocational Qualification in Care at Level 4 in order to ensure she had the necessary qualifications for her role. Arrangements had been made for Regulation 26 reports to be undertaken by an employee who was not directly concerned with the conduct of the care home in order to ensure compliance with the Care Home Regulations 2001. Furthermore, the Registered Provider had developed a new draft quality assurance (QA) audit tool, which had been produced in a format suitable for people with learning difficulties. The home had continued to receive further investment. New carpets had been fitted to the lounge, hallway and bedrooms and a new vinyl floor covering had been fitted to the dining area and part of the hallway. This helps to ensure that the people living in the home benefit from a safe, clean and comfortable environment. What the care home could do better: Staff should continue to explore additional social and recreational activities for the service user who is not accessing day services. This will help to enhance the person`s quality of life and social and recreational opportunities. Handwritten Medication Administration Records (MAR) should be checked and countersigned by another suitably qualified member of staff, to confirm the information is correct as detailed on the relevant prescription. Arrangements should be made for new employees to be supported to complete an induction that meets the requirements of the Skills for Care Induction standards within a maximum 12-week period, to confirm new staff are competent and `Safe to Leave.` CARE HOME ADULTS 18-65 New Hutte Lane, 9 9 New Hutte Lane Halewood Liverpool Merseyside L26 9UD Lead Inspector Daniel Hamilton Key Unannounced Inspection 17th April 2008 08:30 New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Hutte Lane, 9 Address 9 New Hutte Lane Halewood Liverpool Merseyside L26 9UD 0151 291 9139 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Brothers of Charity Mrs Sheila Elizabeth Fitzpatrick Care Home 3 Category(ies) of Learning disability (3) registration, with number of places New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 3 (LD) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 10th April 2007 Date of last inspection Brief Description of the Service: 9 New Hutte Lane is a detached bungalow, which is situated in the Halewood area of Liverpool. The property is owned by ‘Brothers of Charity’, a Registered Charity, which is registered to provide personal care and support to the three people living in the home. The people who use the service have severe learning disabilities and moved to the home following the closure of a long-term institution some time ago. The home is spacious and has a lounge, dining area, kitchen, bathroom, wet room / shower area, four bedrooms (one is used by staff for administration and sleeping in duties) and a garden. The home is accessible via a ramp and the rear garden is adapted for people who have physical disabilities and visual impairments. A purpose adapted mini bus is available for outings and appointments. The Care Home Fee is set at £1278.00 per week. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place over one day and lasted approximately six hours. Three people were living in the home at the time of the visit. A tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. Three staff members were spoken with during the inspection and an advocate was contacted by telephone to obtain feedback on the service provided. Time was spent with each of the people using the service before they visited day care services and / or undertook individualised activities. The people living in the home were encouraged to participate in the inspection process using their preferred methods of communication. All the key standards were assessed and progress / action taken in response to the previous recommendations from the last key inspection in April 2007 was reviewed. The Registered Provider’s head office was visited as part of the inspection in order to check staff recruitment and training records. Feed back on the inspection findings were also discussed with the Organisation’s Area Director during the visit as the Registered Manager was not on duty on the day of the inspection. What the service does well: 9, Newhutte Lane was decorated and furnished to a good standard. The bedrooms of the people living in the home had been personalised and the home continued to receive ongoing investment as required. The people using the service appeared relaxed and comfortable in their home environment. Staff were observed to interact with service users in a positive manner and demonstrated a good understanding of each person’s needs, preferences and preferred routines. An advocate for the people using the service reported; “I’m quite happy with the service provided” and “The staff do what they can to ensure the men are properly looked after.” Essential Lifestyle plans had been developed to ensure key information on each person living in the home had been identified and planned for. A range of supporting documentation was also available and this provided evidence that New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 6 the health care needs of the people using the service were maintained and that service users were encouraged to participate in a range of social and recreational activities. Discussion with staff and examination of training records confirmed staff had access to ongoing training and supervision as part of their role. Records showed that new staff had been correctly recruited and that the welfare of vulnerable adults was protected. There had been one complaint since the last visit which had not been upheld (Please refer to the section entitled ‘Concerns, Complaints and Protection’ for more information). Records showed that the complaint had been acknowledged and investigated by a senior manager within the Organisation (Brothers of Charity). What has improved since the last inspection? Since the last inspection, risk assessments had been updated to ensure potential / actual risks had been individually assessed in order to improve record keeping and accountability. Activity records had also improved and provided more detailed information on the range of activities undertaken by the people using the service. A menu plan had been developed and records of deserts were available to confirm service users received a varied, balanced and nutritious diet. Health Action Plans had been updated and included information on the outcomes of medical appointments. The date, quantity and initials of the person receiving medication into the home had been recorded on Medication Administration Records to provide an audit trail. A copy of the Local Authority’s Adult Protection Procedures had been obtained for staff to reference and staff spoken with demonstrated a good understanding of how to recognise and / or respond to suspicion or evidence of abuse. The Registered Manager had commenced a National Vocational Qualification in Care at Level 4 in order to ensure she had the necessary qualifications for her role. Arrangements had been made for Regulation 26 reports to be undertaken by an employee who was not directly concerned with the conduct of the care home in order to ensure compliance with the Care Home Regulations 2001. Furthermore, the Registered Provider had developed a new draft quality assurance (QA) audit tool, which had been produced in a format suitable for people with learning difficulties. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 7 The home had continued to receive further investment. New carpets had been fitted to the lounge, hallway and bedrooms and a new vinyl floor covering had been fitted to the dining area and part of the hallway. This helps to ensure that the people living in the home benefit from a safe, clean and comfortable environment. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of information has been developed to ensure the needs of the people using the services are met and kept under review. EVIDENCE: The three people who used the service had lived in the home for approximately 12 years. There had been no new admissions since the last visit. Each person living in the home had a personal file. Two files were viewed and both contained a copy of an original ‘Community Nursing Assessment’, which had been completed for each individual before they moved into the home. The needs of the people living in the home had been kept under review as part of Essential Lifestyle Planning processes (a person centred approach to care planning). A ‘Statement of Purpose’ and ‘Service User Handbook’ had been developed by the Registered Provider (Brothers of Charity). The documents contained key information on the services provided and had been designed using pictures, signs and symbols to ensure the format was geared towards the needs of people with learning disabilities. ‘Contract of Agreement’ documents were also available on files. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The changing needs of the people using the service are planned for and supported to promote independence, wellbeing and choice. EVIDENCE: Two personal files were looked at during the visit. Each file contained a copy of an ‘Essential Lifestyle Plan’ together with additional supporting documentation. Essential lifestyle plans contained appropriate information on each individual’s needs, preferences, personal goals and support requirements. Plans had been kept under regular review and updated to reflect any changes. Staff spoken to demonstrated an awareness of the Essential Lifestyle Plan for each service user and confirmed they provided key information, which assisted them in the provision of direct care. Supporting documentation including; pen pictures, risk assessments, learning logs, daily reports, activity sheets, incident and accident records, health care records, personal records and general correspondence were also in place as noted at the last visit. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 11 The people living in the home had little or no verbal communication. Staff demonstrated a good awareness of the individual needs of the people using the service and how to provide person centred care. Throughout the inspection process staff were observed to be respectful and attentive to the people they cared for and service users responded positively to staff interaction by smiling, touching, gestures and / or responsive sounds. The people living in the home were encouraged to take appropriate risks associated with the normal aspects of daily life whenever possible. Health and safety, individual and manual handling risk assessments had been completed for each person using the service in order to address environmental, health and safety and personal risks. Since the last inspection action had been taken to ensure areas of risk had been individually assessed to improve record keeping. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive a healthy diet and are supported to participate in a range of social and recreational activities. This promotes citizenship and ensures a healthy and fulfilling lifestyle. EVIDENCE: Staff reported that there had been no changes to the weekly routines of the people living in the home since the last visit. Two of the people using the service continued to attend a day centre each week and this enabled them to participate in a range of activities with their peers. As previously noted, one person did not interact as well as the other people living in the home due to having complex support needs. Staff should therefore continue to explore additional activities to ensure the person’s social and recreational needs are met. Activity records viewed showed that the people using the service had taken part in various leisure and recreational activities including; swimming, drives out, walks to the shops, visiting the pub, relaxing in the home and gardens, New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 13 shopping and visiting places of interest. A ‘Community Partner’ continued to assist one of the people to access community based activities. Discussion with staff revealed that the service users had also been supported to have a week’s holiday in South Wales during 2007. The home continued to use ‘Learning logs’ to record opportunities for personal development such as developing independent living skills. Logs recorded information on the activity undertaken, the aims of the activity and details of who provided the support. Staff spoken with demonstrated a good awareness of the rights and responsibilities of the people using the service. Essential Lifestyle Plans detailed all the important people in the lives of each person, contact details and the support required to maintain fulfilling relationships. As noted at the last visit, only one person was in regular contact with a relative who also acted as an advocate for the other people living in the home. The advocate was contacted as part of the inspection process and overall was complimentary of the service provided. Comments included; “I’m quite happy with the service provided” and “The staff do what they can to ensure the men are properly looked after.” Staff reported that the home received a weekly food allowance (including cleaning materials) of £112.50 per week. Since the last visit, menu plans had been developed to ensure the people using the service receive a balanced and nutritious diet. Menus viewed had been updated to include information on deserts and provided evidence that the service users had received a healthy diet. Food stocks were satisfactory at the time of the visit. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users is promoted by staff who understand the principles of good care practice. EVIDENCE: Essential Lifestyle and Private plans had been developed which contained information on the personal care and support needs of the people living in the home. Staff spoken with during the inspection demonstrated a good awareness of the principles of best care practice, equality and diversity issues and the need to promote privacy, dignity and independence when providing care to vulnerable adults. The general health care needs of the people using the service and appointments with health care professionals had been outlined in individual ‘Health Action Plans’. The outcomes of appointments had also been documented in ‘Health Action Plan diary notes.’ Records viewed provided evidence of appointments with a range of health care professionals including: general practitioners, dentists, opticians, district nurses, speech and language therapists and / or chiropodists, subject to individual need. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 15 The home had a copy of the organisation’s medication policy as noted at the last inspection. This was entitled; ‘Enabling and Support of Service Users with Learning Disabilities in the Administration of Medicines and Health Related Activities.’ Separate guidance on when to give medication that was “give as required” was also in place. Training records showed that staff responsible for the administration of medication had completed training and this was confirmed in discussion with staff. None of the people living in the home self-administered medication. The home used a blister pack system that was dispensed by Boots pharmacy. Medication was stored in a lockable cabinet in the staff bedroom. Staff reported that no controlled drugs were being stored on the premises. Medication Administration Records (MAR) were viewed for each person. Overall, MAR had been correctly completed to account for the receipt of medication into the home and the administration of medication. It was noted that one MAR chart had been handwritten. Advice was given for handwritten MAR entries to be checked and countersigned by another suitably qualified member of staff to confirm the information recorded is correct as detailed on the relevant prescription. Furthermore, staff were advised to record on medication boxes the date that a supply of medication is opened, to provide an audit trail. Daily balances of medication had been recorded by staff using a separate record and medication administration checklists had been completed periodically to monitor the learning needs and competence of staff responsible for the management of medication. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems had been developed to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The home had a complaints procedure, which had been developed by the Registered Provider (The Brothers of Charity). A full version was available in the office/ staff bedroom and a laminated version was displayed on the wall of the office. The Annual Quality Assurance Assessment (AQAA) for the Service detailed that one complaint had been received and not upheld since the last visit. Staff reported that the complaint concerned the number of drivers based in the home and limited opportunities for service users to get out in the adapted mini-bus. Records were available which confirmed the complaint had been acknowledged and investigated by the Organisation’s Area Director. The complaint had not been upheld as four of the seven staff working in the home were qualified drivers and there was evidence that the people using the service had accessed the mini bus on a regular basis. No complaints, concerns and / or allegations had been received about the service by the Commission for Social Care Inspection since the last visit. A relative / advocate was contacted to obtain feedback on the service as part of the inspection. The relative spoke highly of the service and confirmed he New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 17 was generally satisfied with the standard of care provided. The relative also confirmed that he was aware of the procedure to follow in order to report concerns / complaints. A ‘Protecting People from Abuse Policy’ and a ‘Whistleblowing’ policy had been developed by the Registered Provider for staff to reference. Training records showed that all staff had completed Protection of Vulnerable Adult training and staff spoken with demonstrated knowledge and understanding of how to recognise and respond to suspicion or evidence of abuse. Since the last visit a copy of the local authority’s adult protection procedures had been obtained for staff to read. Furthermore, the Registered Provider had produced a guide for tenants entitled ‘Protecting people from Abuse’ which had been produced in a format that was suitable for people with a learning disability. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant and generally well maintained. This provides the people living in the home with a safe, clean and comfortable environment. EVIDENCE: The Registered Provider (Brothers of Charity) continued to be responsible for the maintenance of the property. A maintenance book was in place to record hazards / work requiring attention and records were available to confirm that the manager and staff undertook monthly health and safety checks. All areas of the home including the bedrooms were viewed. Overall, the property (including the garden) appeared to be maintained to a good standard and provided the people using the service with an accessible, safe and comfortable environment in which to live. The kitchen work surface / units are in need of upgrading and some external parts of the property would benefit from painting. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 19 Rooms viewed had been personalised and photographs of the people living in the home were displayed around the home. (Please refer to the brief description of the service section for more information on the property). Since the last inspection new carpets have been fitted to the lounge, hallway and bedrooms and a new vinyl floor covering had been fitted to the dining area and part of the hallway. Some new fencing panels had also been fitted in the rear garden. Staff were responsible for cleaning and cooking in the home and records showed that staff had completed health and safety, infection control and food hygiene training. Control of Substances Hazardous to Health (COSHH) guidelines were in place and data sheets were available for staff to reference. Cleaning products were stored safely in the home’s kitchen in a lockable cabinet as previously noted. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The welfare of the people using the service is safeguarded as staff are correctly recruited and have access to a range of training opportunities. EVIDENCE: Examination of rotas, direct observation and discussion with staff on duty confirmed the home had a team of seven staff (including the manager). Two staff were on duty through the day. At night, the home had one waking night staff on duty and an additional staff member undertook sleep-in duties. Only one new staff member had started to work in the home since the last inspection. The Registered Provider’s Head Office in Huyton was visited as part of the inspection as recruitment records for staff employed at New Hutte Lane are stored in the Personnel Department. All the necessary records required under the Care Home Regulations 2001 were in place for the new employee and previous inspection records and information received via the Annual Quality Assurance Assessment (AQAA) confirmed the organisation operated a thorough recruitment procedure that was based upon equal opportunities. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 21 The training record for the service detailed that three staff (50 ) had completed a National Vocational Qualification (NVQ) in Care at level 2 or equivalent. An additional member of staff reported that she had also recently completed the award and was awaiting verification. Staff reported the remaining two staff had been nominated to commence a National Vocational Qualification in the near future. A ‘Training Needs Analysis’ record had been completed. This provided details of the training completed by all staff. Records showed that the Organisation (Brothers of Charity) continued to provide staff with a good range of training opportunities to develop knowledge, skills and understanding. Training topics covered a broad range of areas including; safe working practice, care specific, protection of vulnerable adults, equality and diversity and National Vocational Qualifications. Staff spoken with confirmed they had received induction, regular supervision and ongoing training opportunities. The induction records for one new employee were incomplete and did not provide evidence that the employee had been fully inducted in accordance with the Skills for Care induction standards. Evidence was available on file to confirm this matter was being addressed. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems had been established to protect health and safety and to obtain and act upon the views of people using the service and / or their representatives. EVIDENCE: The manager of the home, Mrs Sheila Fitzpatrick is registered with the Commission for Social Care Inspection and has managed the home for approximately two years. Previous records confirm that Mrs Fitzpatrick had previous experience in the management of a small care for people with learning disabilities. Mrs Fitzpatrick had completed the level 4 National Vocational Qualification (NVQ) Registered Managers Award and a range of training that was relevant to her role. The Annual Quality Assurance Assessment (AQAA) for the service detailed that the manager had two outstanding units to complete in order to also attain the level 4 National Vocational Qualification in Care. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 23 Staff spoken with reported that they felt supported in their role by the manager of the home and received regular formal supervision. Records confirmed that arrangements had been made since the last visit for monthly Regulation 26 reports to be completed by a senior manager who was not directly concerned with the conduct of the care home on behalf of the Registered Provider. The Area Director reported that the Organisation (Brothers of Charity) had developed a new draft quality assurance (QA) audit tool, which had been produced in a format suitable for people with learning difficulties. The new QA tool was due to be put into operation within a month, subject to approval from the organisation’s ‘Tenants Forum Group.’ Records showed that the last quality assurance assessment for 9, New Hutte Lane had taken place during July 2006. Following the assessment, an action plan had been produced and records were available to confirm the action plan had been reviewed during November 2006 and November 2007. Arrangements had been made for Knowsley Advocacy Service to provide support to the people using the service, subject to their individual needs and circumstances. The home had a health and safety file, which contained a range of policies and procedures to promote safe working practices and ensure compliance with health and safety legislation. Discussion with staff and examination of training records confirmed that staff had received training in a range of Safe Working Practice topics e.g. Health and Safety, Infection Control, Food Hygiene, First Aid and Fire Awareness etc The Annual Quality Assurance Assessment for the service detailed that equipment and services within the home had received maintenance and inspection checks periodically. A maintenance book was in place to record hazards / work requiring attention and records were available to confirm that the manager and staff undertook monthly health and safety checks. Fire records were viewed for the property. These showed that the smoke detectors were tested on a weekly basis and that a fire drill had been undertaken during December 2007. A fire and generic risk assessment had also been completed as previously noted. No records of emergency lighting tests were available as noted at the previous visit. New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA14 YA20 Good Practice Recommendations Staff should continue to explore additional social and recreational activities for the person who is not accessing day services. Handwritten Medication Administration Records should be checked and countersigned by another suitably qualified member of staff, to confirm the information is correct as detailed on the prescription. New employees should be supported to complete an induction that meets the requirements of the Skills for Care Induction standards within a maximum 12-week period, to confirm new staff are competent and ‘Safe to Leave’. 3 YA35 New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI New Hutte Lane, 9 DS0000021495.V362207.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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